Medicare Progress Note Requirements for Physical Therapy: A Comprehensive Guide for 2023

Why Do Progress Notes Exist?

At its core, the rationale behind progress notes is to justify the care provided. Medicare's primary objective with Part B documentation is to ascertain that the care given aligns with the medical necessity of the services rendered. In simpler terms, a Progress Report should lucidly delineate how the services rendered are medically indispensable for a particular patient. While daily treatment notes are instrumental in justifying billing, periodic reports like the Progress Report are crucial for validating the continuation of services. These reports are the linchpin that affirms your care meets the stringent medical necessity criteria.

Understanding Medical Necessity

Medicare's definition of medical necessity is two fold:

1. For patients undergoing rehabilitative therapy, the patient's condition should exhibit potential for improvement. This improvement should be discernible through objective measurements and achievable within a reasonable and predictable timeframe.

2. For maintenance therapy, which is now permissible, the treatment by the therapist should be essential to maintain, prevent, or decelerate the deterioration of the patient's functional status. The services should be such that they cannot be safely executed by the patient, family members, or other caregivers.

Crafting Progress Reports:

A PT/OT should pen a Progress Report at least once every 10 treatment visits. It's imperative to note that PTAs or OTAs are not authorized to write these reports. Moreover, the time expended in drafting a progress report is non-billable as Medicare deems it encompassed in the treatment time charge.

Essential Elements of a Progress Report:

For a document to qualify as a Progress Report, it must encompass the following elements:

• Start and end dates of the report's period.
• Date of the report's composition.
• Objective accounts of the patient's subjective declarations.
• Objective measurements to showcase progress.
• Status changes in relation to each goal.
• Assessment of progress towards each goal.
• Plans for ongoing treatment and any requisite modifications.
• Updates to goals, discharge plans, or care plans are shared with the physician/NPP.
• Clinician's signature with credentials.